Is an atrial appendage clip the same as a Watchman left atrial appendage closure device?

No, an atrial appendage clip is not the same as a Watchman device—they are distinct left atrial appendage closure technologies with different mechanisms and approaches.

The Watchman is a percutaneous, endocardial plug-style device inserted via transseptal catheterization, while atrial appendage clips (such as the AtriClip/Gillinov-Cosgrove clip) are surgical, epicardial devices applied externally to the LAA during cardiac surgery. These represent fundamentally different approaches to LAA occlusion 1.

Key Distinctions Between Devices

Watchman Device (Percutaneous/Endocardial)

• Deployment method: Inserted percutaneously via transseptal puncture and positioned inside the LAA 1
• Structure: Self-expanding nitinol cage with polyethylene membrane and barbs to anchor within the appendage 1
• FDA approval: Approved for patients suitable for anticoagulation but seeking nonpharmacological alternatives 2
• Evidence base: Demonstrated noninferiority to warfarin for stroke prevention in PROTECT AF and PREVAIL trials, with significantly fewer hemorrhagic strokes 2
• Indication: Class IIb recommendation for patients with AF at increased stroke risk who have contraindications to long-term anticoagulation 2

Atrial Appendage Clips (Surgical/Epicardial)

• Deployment method: Applied externally to the LAA base during open cardiac surgery 1
• Structure: The Gillinov-Cosgrove clip system mechanically excludes the LAA from the epicardial surface 1
• FDA approval: Approved as a surgical device for LAA exclusion 1
• Evidence base: Class IIb recommendation for surgical LAA occlusion in patients undergoing cardiac surgery, upgraded to Level B-NR based on LAAOS III data showing reduced stroke/systemic embolism (HR 0.67) 2, 3
• Limitation: Surgical techniques historically show incomplete occlusion in approximately 50% of cases, though clip-based approaches may perform better than suture-based methods 1

Clinical Decision Framework

For patients requiring LAA closure:

1. Percutaneous approach (Watchman) is appropriate for:

   • Patients with AF and contraindications to long-term anticoagulation
   • CHADS₂ score ≥2 or CHA₂DS₂-VASc ≥3 (per CMS criteria) 2
   • Patients suitable for short-term periprocedural anticoagulation
   • Those seeking alternatives to lifelong anticoagulation due to bleeding risk or poor adherence 2

2. Surgical approach (AtriClip/clips) is appropriate for:

   • Patients already undergoing cardiac surgery for another indication
   • As part of a comprehensive heart team approach to AF management 2
   • When concomitant surgical AF ablation is planned 4

Important Caveats

• Incomplete closure risk: Surgical techniques (especially suture-based) have high failure rates; clip-based methods show better success (73% for excision vs 0% for stapling in one large series) 1
• Anticoagulation requirements: Watchman requires periprocedural anticoagulation followed by dual antiplatelet therapy, then aspirin alone 1. Surgical LAA closure does not eliminate need for anticoagulation in most patients (77% continued OAC in LAAOS III) 3
• Procedural complications: Early Watchman experience showed ~10% adverse events including pericardial bleeding, though this improved with operator experience 1
• Hybrid scenarios: Recent case reports describe using Watchman to close residual stumps after failed surgical AtriClip closure, demonstrating these are complementary rather than interchangeable technologies 5, 6

The choice between these approaches depends on whether the patient is already undergoing cardiac surgery (favoring clips) versus seeking standalone stroke prevention without surgery (favoring Watchman), along with individual bleeding risk, anticoagulation tolerance, and anatomical considerations.